Swedes Rethink Care of Mental Patients

A diplomat's murder turns the tide, again, in a country where coercion is frowned upon but where sterilizations were once common.

STOCKHOLM — With the arrest of a mentally troubled man in the killing of their foreign minister, Swedes' grief has turned to outrage over shortfalls in their psychiatric care system.

Even before Sept. 10, when Anna Lindh was fatally stabbed while shopping at a department store, a spate of deadly attacks by mentally deranged offenders had raised fears that the Scandinavian welfare state could not protect its citizens from psychotic people.

Then, the day after Lindh was attacked, a 23-year-old mental patient from an open-doors psychiatric clinic wandered into a kindergarten in Arvika, 240 miles west of Stockholm, and stabbed a 5-year-old girl to death.

Three decades of reforms have softened Sweden's once-coercive approach to psychiatric care, in which lobotomies and sterilizations were common practice.

But the even more liberal approach instituted in the 1990s has gone too far, critics say, and now innocent people are paying with their lives.

"Death is on the loose.... It's a lottery which one of us runs into him," Jan Guillou, a best-selling author, wrote in a recent newspaper column. "In this massacre, Anna Lindh became victim No. 4."

Guillou was including two attacks in May in the Stockholm area -- an assailant wielding an iron bar who killed an elderly man and injured six people outside a subway station, and a driver who intentionally plowed into a crowd, killing two and injuring 30.

As debate raged about the mentally deranged roaming the capital, news broke that Lindh's suspected attacker had prior convictions and documented psychiatric problems.

The suspect, Mijail Mijailovic, a Swede of Yugoslav origin, hasn't been charged and says he's innocent.

Further stoking the outcry was a letter in the tabloid Aftonbladet from Anders Moquist, whose daughter Sabina was killed at the kindergarten, bitterly denouncing the psychiatric reforms of the 1990s that were intended to help mental patients integrate into society.

"Without this worthless new approach, maybe our recently murdered daughter would have been allowed to live," he wrote.

Sweden takes great pride in its socialized health care. But now many are calling for special prisons and coercive powers to protect the public from psychotic residents.

"The way the law looks now, we must release them even though we know there is an imminent risk that they take drugs again, that they become psychotic again and start fighting again," said Anna Aaberg Wistedt, head of one of two psychiatric emergency care units in Stockholm.

Not everyone, however, believes straitjackets and forced medication are the right cure.

"It makes me a bit nervous if you're going to solve the problems with a new law on coercive treatment," said Johan Cullberg, a psychiatry professor working for the Stockholm county health care authority. "We must not turn back the clock."

Cullberg experienced Swedish psychiatry's dark era, before laws were changed in 1976, when 30,000 people were sterilized under coercion or pressure.

Cullberg and others championed giving patients more say in their treatment. The old mental hospitals were closed, and most patients moved to open-door clinics or government-provided apartments.

The number of hospital beds for the mentally ill dropped to 6,000 from more than 30,000 in the 1960s. The number of mental patients forcibly hospitalized fell to 2,250 in 2001 from nearly 10,000 in 1979, according to the National Board of Health and Welfare.

"Hospital care and coercive treatment have been reduced to the point that a growing number of mentally ill are out in society without adequate support and without demands that they take medication," said Sten Levander, a forensic psychiatry professor at Lund University.

"They become homeless, they abuse drugs and periodically become psychotic. It's in that phase that they commit crimes."

He blamed the left-leaning Social Democratic governments that have ruled Sweden for six of the last seven decades and built its welfare state.

They based psychiatric reforms on ideological assumptions that all coercion is bad and that all people, even convicted criminals, are good, Levander said. "The psychiatry that Cullberg represents is in a ditch on the left. Now we need to get back on the road, and it's quite far to the right."

The present Social Democratic government staunchly defends the reforms and says county and municipal authorities are at fault for not enforcing them properly. But it promises psychiatric care will get budget priority and undergo a national review.